Anaesthesia Delivery Systems

History 01:01

• First public demonstration

‐ Given by WTG Monitor
‐ On 16th Oct, 1846
‐ 16th Oct celebrated as World Anaesthesia Day
‐
• First spinal anaesthesia - AUGUST BIER

Anaesthesia Delivery Systems 03:04

Source 04:18
CYLINDERS

1 kg/cm2 = 14.5 pounds per square inch (psi)

• Oxygen
Colour – Black body with white shoulders
Pressure – 2000 psi (139 kg/cm2)

• Nitrous Oxide
Colour – Blue
Pressure – 760 psi

• Entonox (50% O2 + 50% N2O)

Colour – Blue body with blue & white shoulders
Pressure – 2000 psi
Use – Painless labour

1
CEN R L S LY

• Pressure – 60 psi

• Colour –

▪ White – O2
▪ B UE – N2O
▪ E OW – acuum
▪ Black – Air

IN INDE SYS E

▪ O GEN – 2, 5
▪ N2O – 3, 5
▪ AIR – 1, 5
▪ ENTONO – 7
▪ E IO ( E + O2) – 2, 4

1 6
2 5
3 4
7

DI E ER INDE S E Y SY S E DISS

2
Anaesthesia achine 1 :18
R E ER

RI ER

alothane – Red
Iso lurane – Purple
Sevo lurane – ellow
Des lurane – Blue

reathin ircuits 4:18

• Open – Obsolete
• Semi open – FGF M
• Semi closed
FGF M
• Closed

3
SE I EN CIRC I

• MAP ESON CIRCUIT

• MAP ESON A F

MAP ESON A MAGI CIRCUIT

• S (Spontaneous) FGF = M = 6
• C (Controlled) FGF = 3M = 18 = Not Practical

Magill circuit is o choice or spontaneous ventilation

MAP ESON B & C Obsolete

MAP ESON D

• MC Semi-open circuit
• C FGF = 1.6 M
• S FGF = 2.5 M
4
MAP ESON E Ayre’s T Circuit
Paediatric Semi-open Circuit
MAP ESON F ackson & Rees

- MC used paediatric circuit in 6yrs

20kg
- FGF BAINS

CL SED SE ICL SED CIRC I CIRCLE SYS E

• Soda lime Composition

▪ Ca(O )2 – 80%
▪ NaO – 3%
▪ O – 1%
▪ Water – 15-16%
▪ Silica
▪ Color Indicator – Durasorb Pink ( resh) White (exhausted)

Advantage

• Economical
• Pollution

5
Disadvantage

• Toxic compounds with inhalation agents

- Trilene
- Sevo lurane Compound A (Nephrotoxic)

• Desiccated soda lime

Des lurane (Other Agents) Sevo lurane

CO Burns

New Absorbents
• No compound A
• Amsorb (Calcium hydroxide lime)
• No CO
• ithium hydroxide
• No burns

6
 Critical Care and CPCR
Critical Care 00:09
VENTILATORS
Ventilators

Volume controlled/ Pressure controlled/

Volume Preset Pressure Preset

Advantage  risk of hypoventilation  barotrauma

Disadvantage  risk of barotrauma  hypoventilation

LUNG PROTECTIVE STRATEGY

1) Low TV → 4-6 mL/kg of TBW

2) Plateau pressure < 30mm H2O Prevent
3) PEEP = Start with 5 cm H2O & titrate
Barotrauma
4) FIO2 = < 0.6 (<0.5%)

CPCR 05:43

• RHYTHMS • SEQUENCE
‐ VF C→A→B
‐ PEA 
‐ Asystole 30/18-20 sec

• CRP

BLS ACLS

AIRWAY Manual Equipments

BREATHING M-M, B & M LMA/ETT/TT

CIRCULATION - Cardiac Massage -

- Cardiac Massage -
DEFIBRILLATION AED/PAD Manual

DRUGS - +

1
• CARDIAC MASSAGE

IN ANTS IL REN A LTS

lse e Brachial Brachial/Carotid Carotid

o ression Area - Lower1/3

Lower 1/3rdrdsternum
sternum -

o ression one 2-3 times 1 hand 2 hand

it

o ression Rate - 100-120mt -

o ression e t 1’ 1 ½’ 2-2.4’

Ratio V

it o t A an e
Air a
30 2 30 2 30 2
Sin le
15 2 30 2 30 2
T o

it A an e Air a - C = 100-120/min -
Ventilation 020 – 30 breath
Breath/min
/ min 10

(AHA 2020) Breath/min

ARR T IA ANA E ENT

• Shockable Rhythm
‐ VF
‐ Pulseless VT
‐ Polymorphic VT

360 – Monophasic
150 – 200 – Biphasic

• Non – Shockable Rhythm

‐ PEA
‐ Asystole
‐ Adrenaline

• Drugs

‐ Adrenaline →I/V I/O ET

‐ Concentration - 1 10000
2
 Equipments
Equipments 00:10
AMBU BAG

• 100% O2

GUDELS AIRWAY

• To prevent tongue fall

LARYNGEAL MASK AIRWAY (LMA)

Indications

• Emergency airway for failed/ difficult intubation

• Elective ventilation

Advantages
‐ Avoid complication of intubation
‐ Easy to insert
‐ No laryngoscope
‐ No muscle relaxant Classical / 1st generation LMA
‐ # Cx

Disadvantages
‐  Aspiration

2nd Generation LMA

Igel – MC used in India LMA Supreme

Proseal

1
 A E MASKS

Disadvantages
‐  dead space
‐ Tiring
‐  aspiration

LARYNG S E

MA IN S MILLER

• MC used • Paediatric Adult

• Adult Paediatric all ages

IDE LARYNG S E

‐ % success rate for failed intubation by direct laryngoscope

END RA EAL UBE

• P C
• Low pressure ig volume cuff

Trac eal isc emia

2
 U
• To prevent aspiration
• Can be used in c ildren

S L

Male / no ID mm Male 2 cms

emale / no emale 21cms

0 1yr / no C ildren
Age
12cms
2
Age (years)
1 1 yrs + 4.5 Ex yrs
4
12 1 cms
4 2
4
Ex yrs
4

R A E RE RMED UBE ( RD)

• Oral Sx

LE ME ALLI

• Non – in able
• Neurosurgery ead and nec

D UBLE LUMEN (R BER S AW)

• One lung ventilation

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 YGEN DELI ERY DE I ES

D M M I

N L 0 %

10 L 0 0%

1 L 0 0%

1 L 0 0%

ME ( )

‐ umidification Also nown as artificial nose

‐ ilter

4
 GA – Muscle Relaxant
Sequence of Muscle Blockade 00:13

• Central muscles → limbs

Head & neck > Respiratory, trunk, abdominal > limb
• The sequence at reversal is same

NM Monitoring 01:42

MUSCLES
• Ideal muscles → Corrugators supercilli > Orbicularis oculi
• Most commonly used → Adductor pollicis (Ulnar N.)
• Modality → Train of four

Classification 03:05
• Depolarizers → Depolarization → Refractory
• Non – Depolarizers → Complete antagonist

Suxamethonium 04:47

• Succinylcholine
• Ideal for intubation
- Onset = 20-30 sec
- Duration < 10 min
- Metabolized by pseudocholinesterase
• Systemic effects
- Hyperkalemia
- Increase IGP, IOP & ICT
- Muscle pains (40-50%)
- Malignant hyperthermia
• C/I
‐ Hyperkalemia
‐ Upto (due to extra junctional receptors)
▪ 3 months after trauma
▪ 6 months after stroke
▪ 1 year after burns
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 ‐ Muscular dystrophies

• Prolonged block
1) Lo pseudocholinesterase
- Hepatic failure
- Hypoproteinemia
2) Abnormal pseudocholinesterase
(Atypical)
- Dibucaine no.
3) Phase 2 block (Dual block)
- High doses

Non – e olari ers 11:53

• Maintenance
• Obsolete agents
- D – tubocurare – irst
- Gallamine – Cross placenta
- Doxacurrium – % excreted unchanged

• Current day agents

1) ecuronium
- Most cardiac stable
2) Pancuronium
- NA → HT
3) Atracurium
- Hoffman degradation
- MR → Renal failure
Liver failure
- S/E → Release histamine
Laudosine → convulsions
4) Cisatracurium > Atracurium
- No histamine released
- 1/5th laudosine
5) Rocuronium
‐ ast onset = < 0 sec
‐ Non dep → Intubation
2
 6) Rapacuronium
‐ ronchospasm ( -10%)
) Mivacurium
- Metabolized by pseudocholinesterase
- 10 min
- MROC → Day care Sx
) Gantacurium
- Onset & Duration Suxamethonium

REVERSAL

• Cholinesterase inhibitors
- Neostigmine Glycopyrrolate ( lock muscarinic S/E)
• Gamma cyclodextrins (sugammadex)
- Directly binds
- Reverse steroids

3
 GA - Complications
Complications of General Anaesthesia 00:09

• Aspiration

‐ Preventable
‐ Nil orally
‐ Anaesthetic management for high risk

A.O.C → Regional

GA → Rapid Sequence Induction (RSI)

Preoxygenation

Induction → Ketamine → SCh

Bag & Mask Cricoid Pressure

(C/I) (Sellick Manoeuvre)

Intubate

CNS

• Convulsions
- Hypoxia
- Methohexitone (propofol, etomidate)
- Sevoflurane (Enflurane)
- Atracurium/Cisatracurium (Laudanosine)
- LA toxicity
• Pain
‐ 2nd MC post-op

ANAPHYLAXIS

• Except inhalational agents

• MC – Antibiotics

1
 I

• Nausea and vomiting → Most common post-op complication

H AL

• Malignant hyperthermia
• Causative agents
- Suxamethonium → MC implicated
- olatile agents → Maximum – Halothane
• reatment
- Stop triggering agent
- Hyperventilation
- Rx K
- Rx Arrhythmia
- Rx hyperthermia
- Rx acidosis
- Maintain urine output

• Management of susceptible patient

‐ A.O.C → Regional
‐ GA → I/ → Propofol
Maintainence → I Opioids
‐ MR → SCh → C/I
Non-dep → elay MH

P SI I N LA

• Peripheral Neuropathy
- MC – lnar Nerve
• enous Air Embolism
- Sitting
- ml
- EE ( .2 ml)

2
 GA – Inhalational Agents
- Maintenance

CLASSIFICATION
Inhalational agents

Current Use Obsolete

Gaseous Volatile
- N2O - Halothane
- Xenon - Isoflurane
- Sevoflurane
- Desflurane

Potency α 1 / MAC
‐ MAC (Min alveolar conc.)
‐ Most potent – Halothane
‐ Least potent – Overall – N2O
Volatile – Desflurane

Blood Gas Coefficient / BG solubility

• Indicator of induction & recovery
• Fastest induction – Overall – Xenon
- Current – Desflurane
• Slowest induction – Halothane

Individual Agents

Nitrous Oxide 06:40

• 35 times more soluble than nitrogen
• Least potent
• Side effects –
1. Expansion of air spaces: Absolutely C/I in Pneumothorax, Pneumopericardium,
Pneumoencephalus

1
 2. Bone marrow aplasia
Prolonged use
3. Sub-acute degeneration of spinal cord
. Megaloblastic anemia ( –12hrs)
5. eratogenic effects
. Destructive to o one

e o 0:

• Advantages
- No S/E li e nitrous oxide
- Supersedes in anesthetic properties
• Disadvantages
- Very expensive
- Can increase airway resistance

O N : 6

• Non – irritant → Smooth induction

• Most potent
• Slowest recovery
• Sensiti es heart to adrenaline
C/I – pheochromocytoma
• Not preferred for asthmatics
• Halothane hepatitis

O N :00

• Irritating induction
• IAOC – Cardiac
Min  CO
Isoflurane doesn’t cause coronary steal

N 6: 0

• Isomer of Isoflurane
• Irritating induction
• High vapor pressure

2
 • Low boiling point
• Can produce CO
• Least potent
• Lowest blood gas coefficient
• Minimal metabolism ( .1 )
• No fluoride
IAOC – enal
• Systemic effects
Isoflurane
→ ( ) Sympathetic : IADC -Shoc

O N :4

• IAOC
1. Pediatric induction – smoothest
2nd - halothane
Isoflurane & Desflurane – can’t be used for induction
2. Asthma – Max bronchodilators
3. Neurosurgery – Min IC
. Hepatic patient – Min HBF

• S/E
1. Compound A
2. Burns of respiratory mucosa
3. Convulsions – very rare

Advantages
- Cheapest
- Safest
- Compete
Disadvantages
- Irritating Induction
- Nausea & Vomiting
- Inflammable & Explosive
3
 O 4: 0

• He O2
• Upper airway obstruction

N ONO : 4

• N2O O2
• Labor analgesic
• Dental

4
 Introduction to GA and IV Agents
General Protocol 00:21
1) Preoxygenation

2) Induction → IV (propofol)

3) Suxamethonium

4) Intubation

5) Maintenance → 75% N2O/ Air + 25% O2 + Inhalational agent + Non –

depolarising muscle relaxant
6) Reverse

7) Extubation

IV Agents 04:50

IV Agents

Barbiturates Non – barbiturates

1) Thiopentone
• Alkaline pH (10.4)
• Redistribution
• Anticonvulsant
• Cerebroprotective -  CMR by 30-40%
• Complication: Intra-arterial injection - Vasospasm
• Prevention - 2.5%, Inject slowly
• Rx
- Don’t remove needle/cannula
- Vasodilators
▪ Papaverine
▪  blockers
▪ Lignocaine

1
 - Stellate ganglion block
- Heparin
- arfarin 7-14 days

) ethohe itone
• Epileptogenic
• I/V → EC

) opo o
• Prepared in soyabean oil → Painful
• Contains egg lecithin → iscard after 6 hours
• Half – life → 2-3hrs
• Anti – emetic
• IV agent of choice
- Induction
- ay care Sx
- Controlled asthmatics

) nto i te
• CV → Stable
• I/V → Cardiac patient
Vascular Sx
• S/E → Adrenocortical suppression

) en o i epine
• Anxiolytics
• Amnesia
• Mida olam
- t 1/2 → 2 hours
- Painless

) et ine
• issociative anaesthesia
• NM A receptor
• Advantages
- I/V of choice for
▪ Shock patients → (+) Sympathetic
▪ ull stomach → Pressure airway reflexes
▪ Active asthmatics → Rx – Refractory status asthmatics

2
 ▪ Low cardiac output (CH ) - (+) Sympathetic → C.O
▪ R – L shunts ( O ) - (+) sympathetic → SVR →  Shunt
• S/E
- Vivid reactions
▪ Hallucination (40-50%)
▪ reaming
▪ elirium
▪ Rx → B s (mida olam)
- Increased pressures
▪ IOP, I P, ICP

) pioi
• Analgesia
• Receptors
µ µ1 - Analgesic
µ2 – Resp. depression
Κ Analgesic at spinal level
δ

Nociception – Endogenous

• S/E –
‐ Respiratory depression
‐ Muscle rigidity – ooden chest syndrome
‐ Constipation – Opioid bowel syndrome
‐ Construction of Sphincter of Oddi
- Biliary colic is not an absolute C/I

) e iphe nt oni t
• Methylnaltrexone and Naloxegol

) α2 oni t
• Adjuvant and sedation
• Clonidine (obsolete)
• exmedetomidine – less S/E

3
 Pre- Operative Assessment and Monitoring
Preoperative Assessment 00:09

• Pre anesthetic care

Airway Assessment 00:49

1. Modified Mallampati Score

Faucial pillar Faucies Uvula Soft Oral Sx

palate

I ✓ ✓ ✓ ✓ Easy

II X ✓ ✓ (major) ✓

III X X Tip ✓ Difficult

IV X X X X Impossible

2. TM distance  6.5 cms

3. Neck movements

Investigations
• Guided by associated comorbidity

ASA Grading

I → Normal healthy patient

II → Mild with no functional limitation
III → Moderate with functional limitation
IV → Severe – incapacitating
V → Moribund
VI → Brain dead
E → Emergency surgery

Premedication 08:20
• Done with aim
• Most common goal → Relieve anxiety

1
FASTING

Solid → 6hrs
Non veg atty → hrs
lear fluids → 2hrs
Breast mil → hrs

Management of re – xisting rug T erap

TO STO TIM TO STO

Viagra 2 hrs
2 nticoagulants (warfarin) 5 days
ntiplatelets – spirin 2 hrs except Recent MI
Recent Stro e
oronary Stent
lopidogrel 5 days
ral contraceptives wee s
high dose estrogen
5 erbal medication days
6 Smo ing wee s
E inhibitors RB 2 hrs

Morning ose to e Ommited

. Diuretics
2. Topical creams
. ral hypoglycemics

Modifications e uired
. holinesterase inhibitor – minimal
2. Steroids
. TT

ids :

Maintenance → 2
R
eplacement → rystalloids olloids

2
 onitorin :

• NS
- Depth of naesthesia
. Bispectral index

2. Entropy

• S monitoring
- IBP → Gold standard
- E G → II – rrythmia
V V V5 – Ischemia
- Trans Esophageal Echocardiography (TEE) → Best

• espirator monitoring
- Pulse oximeter → Sp 2

- imitations → an’t detect ab (N) Hb

ximeters – Gold standard

- apnography → ET 2 along with graphy
- ses – Surest confirmation of inhibition
Extubation
Et 2
pnea
ardiac arrest Graph flat line
ir embolism
Malignant hyperthermia

‐ apnography graphs

3
Temperature
• ypothermia – ore temperature < 35⁰C
• Sites
ccurate – Pulmonary .
M used ower oesophagus
(best)

4
 Regional Anaesthesia - Local Anaesthetics

Sequence of Nerve Blockade 00:18

• Nerve fibres
‐ Peripheral nerve block (PNB): A > A > A =  > B > C
A>B>C
‐ Central nerve block CNB: B > A > C

• Functional
‐ PNB : Motor > Sensory > Autonomic
‐ CNB : Autonomic > Sensory > Motor

• Recovery
‐ Reverse
‐ PNB : Autonomic > Sensory > Motor
‐ CNB : Motor > Sensory > Autonomic

Mechanism of Action 04:09

• K+
• Ca2+
• Cl-
• Mainly Na+ channel block

Toxicity 05:18

• CNS → Earlier
• CVS

Prilocaine 05:40

• Extrahepatic metabolism
• High doses – Methemoglobinemia

1
 i nocaine 0 :
• MC used

ithout adrenaline ith adrenaline

( in 2 )
uration - min 2- hrs
Max sa e doses mg kg mg kg

u ivacaine 08:58
• uration → 2- hrs
• Max sa e dose → 2 mg kg
• Cardiotoxicity
- Bradyarrhythmia → achyarrhythmia
- Ventricular achycardia
C - Amiodarone

• S – B P VACA NE
• ess cardiotoxicity

R N > EV B P VACA NE

• cardiotoxicity
• rd
less potent

M A AM 1 :44

• 2 lignocaine + prilocaine

2
 RA- Peripheral & Central Nerve Blocks
Peripheral Nerve Blocks 00:09
BRACHIAL PLEXUS BLOCK

• Interscalene → Ulnar N. gets spared

• Supraclavicular → MC used
→ Pneumothorax (0.5 - 6%)
• Infraclavicular → Failure rate 
• Axillary → Musculocutaneous N. gets spared

STELLATE GANGLION BLOCK

• Indications
- RSD
- Intra-arterial thiopentone
• Site
- Tubercle of transverse process of C6 (Chassaignac tubercle)

SIGNS OF SUCCESSFUL BLOCK

• Horner syndrome
• Conjunctival congestion – Earliest sign
• Guttmann’s sign (nasal stiffness)
• Muller sign (TM congestion)

CENTRAL NEURAXIAL BLOCKS 04:56

• Spinal
• Epidural

ANATOMY

• Extension of spinal cord

Infant → Lower border of L3
Adult → Lower border of L1

1
• Structures Encountered

1
2
1-7
3
4
1-5
5
6
7

Spi al A Aes hesia 09:00

P
‐ Sitting
‐ Lateral

N
N

Dura cutting Dura separating (Pencil tip)

Post spinal
Headache

‐ Lignocaine 5% heavy (hyperbaric) S CSF .5% Dextrose

‐ upivacaine 0.5% hyperbaric % Dextrose

• Hypotension
- Sympathetic bloc ade → vasodilation → R→ C
• radycardia
- Sympathetic bloc → Parasympathetic (cranial) overdose
- Cardioaccelerator fibres (T1-T )

2
• High spinal Total spinal

• Intraoperative
- Hypotension
MC complication
Preloading is not recommended
• Postoperative
- Urinary retention
MC post-op complication

• Post spinal headache (post dural puncture headache)

- Low pressure meningovascular headache
- Nec rigidity
- Posture relation
- Prevention - Small gauge Pencil tip needles
- Management

1ST – Fluids nd
– Tryptans
Analgesics I Caffeine
Supine 5% C
Caffeine

No Response HRS

3rd autologous epidural blood patch

Meningitis
-
Spinal → Mc → Streptococcus iridians
Continuous Epidural → Staphylococcus epidermis

Epi ral a aes hesia 5:0

• Extradural
• Needle – Tuhoy’s

3
• Techni ue – Loss of resistance
• Advantage over spinal
- Less hypotension
- No post-spinal headache
- Level end duration of bloc can be changed
• Disadvantage
- Patchy bloc
- Total spinal

Ca al Block 5:0
• Epidural
• Sacral hiatus
• Pediatric
• Perineal Sx

C/I 5:4
A

• Raised ICT
• Coagulopathies Anticoagulants
• Patient refusal
• Severe hypovolemia
• Infection at local site
• Fixed cardiac output lesion (AS MS) → If severe

4
 Speciality Management
Speciality Management 00:08
CVS

RA / GA

▪ Induction (I) – Etomidate

▪ Maintenance (M) – Isoflurane
▪ Muscle Relaxant (MR) - Vecuronium

Respiratory System (Asthma/COPD)

▪ A.O.C – RA
GA
▪ I – Controlled – Propofol
▪ Uncontrolled – Ketamine
▪ M - Sevoflurane
▪ MR - Steroids

Hepatic

▪ A.O.C – GA
▪ I – Propofol
▪ M - Sevoflurane
▪ MR - Cisatracurium > Atracurium

Renal

▪ A.O.C – GA
▪ I – Propofol
▪ M - Desflurane
▪ MR - Cisatracurium > Atracurium

Neuromuscular disease (like Myasthenia Gravis)

▪ A.O.C – RA
GA
▪ I – Propofol
▪ M - Desflurane (Max MR)
▪ MR - Mivacurium / Cisatracurium > Atracurium

1
Anaesthesia or Covid

▪ A.O.C – RA
GA
‐ Rapid se uence
‐ Video lar n oscope

Neurosur ical Anaesthesia

▪ I – iopentone
▪ M - Sevoflurane (Max MR)
▪ MR - SC -C/I
on dep – safe

O stetric Anaesthesia
SCS
▪ A.O.C – Spinal
In case of GA
‐ Rapid se uence
Painless la our – um ar epidural

Paediatric Anaesthesia
GA
▪ I – st – Propofol
nd
– In - Sevoflurane
▪ M - Desflurane
▪ MR - Cisatracurium > Atracurium
▪ Cuffed tu es
▪ RA is not C/I

Anaesthesia or Day care

RA / GA
▪ Avoid supraclavicular (due to ris of pneumot orax)
GA
▪ MA > E
▪ IV – Propofol
▪ In - Sevoflurane > Desflurane
▪ MR - Mivacurium
▪ D – Mida olam
▪ Opioid – Remifentanil

2
Anaesthesia or laryn oscopy
▪ Ideal as – Ar on (expensive)
▪ MC as – CO ( i l diffusi ilit )